Inspection Reports for Bethany Home Retirement Center

1005 Lincoln Ave, Dubuque, IA 52001, IA, 52001

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Deficiencies per Year

4 3 2 1 0
2020
2021
2023
2024
2025
Severe High Moderate Low Unclassified

Census Over Time

56 60 64 68 72 Oct '20 Dec '20 Dec '21 Mar '23
Inspection Report Complaint Investigation Deficiencies: 0 Aug 5, 2025
Visit Reason
An investigation for complaint 1797676-C was conducted from August 4, 2025 to August 5, 2025.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
Investigation for complaint 1797676-C; facility found in substantial compliance.
Inspection Report Annual Inspection Deficiencies: 0 May 1, 2025
Visit Reason
An annual recertification survey was conducted from April 28, 2025 to May 1, 2025.
Findings
The facility was found to be in substantial compliance at the time of the survey.
Inspection Report Complaint Investigation Deficiencies: 0 Sep 27, 2024
Visit Reason
A complaint investigation for complaint #122556-C was conducted on September 27, 2024.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #122556-C was investigated and the facility was found to be in substantial compliance.
Inspection Report Annual Inspection Deficiencies: 0 Jun 27, 2024
Visit Reason
An annual recertification survey was conducted from June 24, 2024 to June 27, 2024.
Findings
The facility was found to be in substantial compliance.
Inspection Report Complaint Investigation Deficiencies: 0 Apr 22, 2024
Visit Reason
An investigation of facility reported incident #117190-I and complaint #119545-C was conducted on April 22 - 23, 2024.
Findings
Incident #117190-I was not substantiated. Complaint #119545-C was not substantiated.
Complaint Details
Investigation of complaint #119545-C and incident #117190-I; both were not substantiated.
Report Facts
Incident number: 117190 Complaint number: 119545
Inspection Report Plan of Correction Deficiencies: 0 Apr 19, 2023
Visit Reason
The document is a plan of correction submitted following a prior deficiency finding, indicating the facility's acceptance of compliance and corrective actions.
Findings
The facility was found to be in compliance based on acceptance of a credible allegation of compliance and plan of correction, effective April 6, 2023.
Inspection Report Annual Inspection Census: 67 Deficiencies: 2 Mar 30, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey combined with an investigation of complaint #111963-C.
Findings
The facility failed to meet professional standards of quality related to medication administration and dietary staff compliance with food safety requirements. The complaint was not substantiated. Deficiencies included improper medication handling in a locked Memory Care Unit and failure of dietary male staff to wear beard restraints as required by policy.
Complaint Details
Complaint #111963 was investigated and found to be not substantiated.
Severity Breakdown
Level D: 2
Deficiencies (2)
DescriptionSeverity
Failure to administer medications according to accepted standards of clinical practice within a locked Memory Care Unit, including leaving medications unlocked and unsupervised.Level D
Failure to ensure dietary male staff wore beard restraints as required by food safety standards.Level D
Report Facts
Census: 67 Deficiencies cited: 2
Employees Mentioned
NameTitleContext
Staff ERegistered Nurse (RN)Named in medication administration deficiency for leaving medications unlocked and unsupervised
Staff FLicensed Practical Nurse (LPN)Interviewed regarding medication administration and ophthalmology orders
Staff GRegistered Nurse (RN)Interviewed about medication administration expectations
Staff HRegistered Nurse (RN)Interviewed about medication administration expectations
Dietary ManagerNamed in deficiency related to dietary staff not wearing beard restraints
Staff ACookObserved not wearing beard restraint in kitchen
Staff BDietary AideObserved not wearing beard restraint in kitchen
Staff CDietary AideObserved not wearing beard restraint in kitchen
Staff DDietary AideObserved not wearing beard restraint in kitchen
Inspection Report Renewal Census: 61 Deficiencies: 4 Dec 14, 2021
Visit Reason
The inspection was conducted as a Recertification Survey and Facility Reported Incidents #97322 and #99153, including a substantiated incident #97322-1, related to medication administration and resident supervision.
Findings
The facility was found deficient in administering medications according to professional standards for 1 of 12 residents observed, and failed to provide adequate supervision and safety interventions to prevent elopement for 1 of 12 residents sampled. Additional deficiencies included improper food preparation and failure to report an elopement incident to the state.
Complaint Details
The facility reported Incident #97322-1 was substantiated. The complaint involved failure to administer medications properly and failure to provide adequate supervision leading to resident elopement. Immediate jeopardy was identified related to elopement on December 9, 2021, which was abated by implementing alarms and enhanced supervision.
Deficiencies (4)
Description
Failed to administer medications within professional standards for 1 of 12 residents observed during medication administration.
Failure to provide adequate assessment and supervision for resident who exited the building and was found outside without injuries, resulting in immediate jeopardy.
Food was incorrectly served to 2 of 3 residents, serving ground meat instead of physician-ordered pureed diet.
Failed to report an elopement for 1 of 1 residents sampled to the state within required timeframe.
Report Facts
Census: 61 Residents observed for medication administration: 12 Residents sampled for elopement supervision: 12 Residents with food service errors: 2 Residents with wandering incidents: 1
Employees Mentioned
NameTitleContext
Susan WestmarkAdministratorNamed as Administrator signing plan of correction and involved in oversight
Staff ICertified Medication AideObserved placing medication cup and involved in medication administration deficiency
Staff JRegistered NurseInvolved in medication administration observation and supervision
Staff DDirector of NursesProvided statements regarding medication policies and elopement supervision
Staff FLicensed Practical NurseFound resident outside after elopement incident
Staff HCertified Nurse AideAssisted resident back into building after elopement
Staff ELicensed Practical NurseReported resident behavior prior to elopement
Inspection Report Routine Census: 62 Deficiencies: 0 Dec 10, 2020
Visit Reason
A focused COVID-19 infection control survey was conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19 during the survey conducted from December 9 to December 10, 2020.
Inspection Report Complaint Investigation Census: 62 Deficiencies: 0 Oct 20, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an investigation of facility reported incident #91923-I and complaint #91922-C from October 14 to 20, 2020.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Complaint #91922-C and facility reported incident #91923-I were not substantiated.
Complaint Details
Complaint #91922-C and facility reported incident #91923-I were investigated and found not substantiated.
Report Facts
Total residents: 62
Inspection Report Abbreviated Survey Deficiencies: 0 Jun 9, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/9/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.

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